MID TERM REVIEW OF MID TERM REVIEW OF REPRODUCTIVE AND CHILD REPRODUCTIVE AND CHILD HEALTH PROGRAMME – IIHEALTH PROGRAMME – II

NGO ConsultationNGO Consultation

17 December 2008

1

Overview of the Presentation

2

RCH II / NRHM Programme

Goals

Strategies

Progress of Interventions

3

CURRENT STATUS VIS-A-VIS RCH II/NRHM GOALS

 RCH II Goal

Indicator

All India Status(Source of Data)

 Targets for No. of states having achieved

% of total population

(for states having

achieved)

10th Plan (2007)

RCH II

/NRHM (2012)

10th Plan

targets

RCH II

/NRHM targets

10th Plan

targets #

RCH II /NRHM

targets #

MMR(per lakh live births)

398(SRS

1997-98)

301(SRS

2001-03)

<200 <100 8 Nil 43.1% Nil

IMR(per 1000 live births)

71(SRS 1997)

55(SRS 2007)

<45 <30 13 5 31.1% 3.7%

TFR 3.3(SRS 1997)

2.8 (SRS 2006)

2.3 2.1 10 5 44.3% 25.0%

Note:

1. # Census 2001

2. Current MMR and TFR data pre-dates RCH II, while IMR data is for first year of RCH II.

3. Union territories (except Delhi) have been excluded in the findings

RCH II STRATEGIES

4

5

MATERNAL HEALTH STRATEGIES

Demand Promotion: Janani Suraksha Yojana.

Services: Public sector Early detection of pregnancy through rapid detection kits.

Quality ANC, PNC, Institutional and Safe Delivery

Skilled Attendance at birth (domiciliary & health facilities).

Essential and Emergency Obstetric Care

Operationalise facilities- FRUs, CHCs, 24 Hrs PHCs.

Multi-skilling of doctors to overcome shortage of critical specialities (training on Life saving

Anaesthesia Skills and Emergency Obstetric Care)

Strengthen Referral Systems including transport.

Management of RTIs & STIs at PHCs & CHCs/FRUs.

Safe Abortion Services – PHC/ FRU level

Services: Private sector Accrediting private health institutions under JSY

Fixed package for contracting out services (e.g. Chiranjeevi scheme in Gujarat)

Supporting Private Gynaecologist to establish their nursing homes in Tribal area where

Chiranjeevi scheme is not working (in Gujarat)

6

Key Features

Early Registration

Referral Transport (Home to Health Institution)

Promoting Institutional birth

Post delivery visit and reporting

Family Planning and Counseling

JANANI SURAKSHA YOJANA (JSY)

Supported by

ASHA/ any Link

worker

Cash Assistance

7

CHILD HEALTH STRATEGIES

Integrated Management of Neonatal and Childhood Illnesses Pre-service and In-service training of providers Improving health systems (e.g. facility upgradation, availability of logistics, referral

systems) Community and Family level care

Home Based Newborn and Child Care/ Facility Based Newborn Care Infant and Young Child Feeding

including Improving Early and Exclusive Breastfeeding and Complementary Feeding

Nutritional Rehabilitation Centre for Management of Acute Malnutrition Reduction in morbidity and mortality due to Acute Respiratory Infections (ARI)

and Diarrhoeal Diseases Supplementation with micronutrients: Vitamin A & iron School Health Program

IMMUNISATION INTERVENTIONS

8

Introduction of new vaccines based on disease specific mortality and morbidity indicators – Hepatitis B

System Strengthening :

• Activity based funding to strengthen service delivery

• Alternate vaccine delivery to ensure reach into villages

• Alternate Vaccinators to ensure sessions are held

• ASHA/Link workers used for Social Mobilization to ensure demand creation in community.

• Strengthening Supportive supervision

• Half yearly meeting at State with districts to ensure monitoring.

• Support for POL to assist active supervision

Capacity Building: Trainings at all levels for all aspects of immunization service delivery

Monitoring and supervision of the programme at service delivery level

Demand generation: Social Mobilization

FAMILY PLANNING STRATEGIES

9

1. Reduce unmet need for spacing methods

2. Reduce unmet need for terminal methods

3. Increasing male participation

4. Expanding contraceptive choices

5. Ensuring quality care in Family Planning

6. Introducing indemnity insurance

7. Revision of compensation to acceptors of sterilization

8. Social marketing of Family Planning products

9. Strengthening contraceptive logistics

10. Emphasis on promotion of IUD 380 and Emergency Contraception

PROGRESS OF RCH II

10

11

INSTITUTIONAL DELIVERIES

99.499.196.494.0

76.171.868.665.163.663.3

56.555.949.849.248.247.146.946.345.544.3

35.330 27.724.5

18.117.8

0.0

20.0

40.0

60.0

80.0

100.0

120.0

DLHS III DLHS II

11

JSY PERFORMANCE

Allocation for 2008-09 is Rs. 1281.47 crores

13.10

7.39 31.58

73.29

Rs. 755 cr

Rs. 256 cr

Rs. 38 cr

Rs. 372 cr

0

10

20

30

40

50

60

70

80

2005-06 2006-07 2007-08 2008-09

No

. of

Ben

efic

iari

es

Lak

hs

0

100

200

300

400

500

600

700

800

Exp

end

iture R

epo

rted (R

s. Cro

res)

Beneficiaries (lakhs)

Expenditure (Rs. Crores)

TillSep '08

Till Jun'08

9.71

Till Jun'07

12

MATERNAL HEALTH PROGRESS

Training of MOs in anaesthesia and EmOC and ANMs/SNs in

SBA has gained considerable momentum.

Achievements in MH trainings (cumulative):

Facility Target Achievement*

FRU 3,360 1,652

24-hour PHC 14,225 11,135

13

Trainings 06-07 07-08 08-09

(upto Sep)

Anesthesia (MOs) 26 398 534

EmOC (MOs) 40 101 213

SBA (SN/ ANMs) 1800 5105 17922

Achievements in Facility Operationalisation:

* – NRHM data, Aug 2008

VILLAGE HEALTH AND NUTRITION DAYS

KEY COMPONENTS Registration of pregnancy

ANC

PNC

Birth planning

Immunization

Counselling on nutrition

Counselling on family planning

Services for sick children

30.48

44.76

13.53

0

5

10

15

20

25

30

35

40

45

50

Nu

mb

er o

f V

HN

Ds

(lak

hs)

2006-07 2007-08 2008-09 (tillAug 08)

14Based on data from NRHM

PROGRESS: 2005-08

Maternal health Institutional deliveries have increased in most of

the states in the country. High focus states have shown tremendous growth. Maximum increases in MP, Orissa, Rajasthan, Assam, and Bihar.

Ten fold increase in JSY beneficiaries to 73.29 lakhs in 3 years. Greater transparency in JSY implementation seen during state visits.

JSY has led to huge increases in institutional delivery: MP (21.9% points); Rajasthan (12.2% points); Bihar (11% points); Orissa (10.2% points).

15

PROGRESS: 2005-08

Maternal health (contd.) Facility operationalisation: 49% and 46% of FRU and 24x7

PHC targets achieved. Multi skill training of doctors in EmOC and LSAS and “task

shifting“ to ANMs and SNs gaining momentum. Referral transport systems, in general have been given

emphasis across states; visits to MP and Gujarat indicated wide use of the Janani Express Yojana and EMRI 108 service respectively.

Field visits indicate availability of NISHCHAY (Rapid pregnancy testing kit) with peripheral health functionaries. A rapid assessment conducted recently indicates over 82% of ASHAs themselves performed tests. Need to ensure subsequent counselling/ follow up.

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17

Coverage in Child Immunization

80.482.6

52.5

79.3 79.5

59.3

74

67.1

30.3

63.6

76.7

36.238.9

79.9

62.4

70.8

89.8

59.8

50.0

71.7

41.4

48.8

78.0 75.8

54.148.0

0.010.020.030.040.050.060.070.080.090.0

100.0

DLHS-III DLHS-II

17

PROGRESS: 2005-08

Child Health Full immunisation has improved across states; particularly in

Assam, Jharkhand, Rajasthan, Bihar, Uttarakhand and Sikkim.

Drop outs between BCG and measles, and within doses, have declined.

The negative trend seen in full immunisation coverage between CES 2005–2006 has been reversed in DLHS III in Rajasthan, Punjab and Karnataka.

Improvements in early initiation of breastfeeding and exclusive breastfeeding.

IMNCI implementation has accelerated: 193 districts with 71,355 personnel trained; pre-service IMNCI underway in 62 medical colleges.

18

Programmatic interventions in Family Planning

1. Addressing the unmet need in terminal methods

Fixed Day Static services Developing Skilled manpower for the same

2. Increasing Male participation through intensive promotion of NSV

3. Promotion of IUDs as a short & long term spacing method

4. Promotion of Emergency Contraceptive Pills5. Increasing Basket of choices for

Contraceptives 19

Promotional Interventions in FP

Revised COMPENSATION scheme Family planning INSURANCE scheme Ensuring Contraceptive supply Promoting PPP/ Social Marketing Promoting contraception through

increased ADVOCACY

20

FP Systems: Mechanisms for monitoring for quality

Quality Assurance Committees Monitoring all aspects of RCH

Technical manuals updated Standards and QA in Sterilization services IUD for MOs and Nursing Personnel Standard Operating Procedures for

sterilisation camps Emergency Contraceptive pills Fixed Day Strategy in sterilisation services

21

Progress of FP Indicators

TFR

CPR

Contraceptive use

reduced from 3.3 to 2.9 (SRS 05)

increased to 45.7 % (NFHS 3)

increased from 48.2% to 56.3 % (NFHS 3)

Indicators

Unmet need

NFHS 2 NFHS 3

Total 16 13

Permanent 8 7

Spacing 8 6

PROGRESS: 2005-08

Behaviour change communication Strong NRHM brand.

State-specific BCC strategies have been developed in Chhattisgarh, Jharkhand and Uttar Pradesh, while district specific BCC strategies are underway in MP.

Other key state level initiatives include innovative IPC tools in Uttarakhand, BCC kit and training module developed by Chhattisgarh and IPC tools such as flip book for ASHAs in UP, BCC corners at the PHC level in Gujarat, pilot to involve tribal community healers and utilizing Kalyani clubs in Orissa.

24

PROGRESS: 2005-08

Monitoring and evaluation Overall, monitoring of the RCH II program has strengthened

since its inception. NFHS III 2005/6 released in 2007; DLHS III results released. MoHFW has rationalised the indicator set for the national

MIS; a web based system for reporting has been launched. Capacity of the M&E division strengthened. Data

Triangulation Cell set up. Several examples of states which have developed better

M&E tools: GIS mapping in Gujarat and Orissa; pregnancy cohorts in TN.

25

INNOVATIONS Range and spread of innovations is impressive, and over 200 have been identified so far. These cover:

Promotion of safe motherhood and institutional deliveries (24)

Innovations have been piloted within the NRHM/RCH II parameters of decentralization, flexibility, and results based performance

Equity is a central theme in a large number of innovations. Several are state specific but some span several states, or

are similar across states (e.g. EMRI, Chiranjeevi-like schemes to promote safe motherhood/ institutional deliveries)

Several states have undertaken evaluation of their innovations, while some innovations have been evaluated nationally.

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INNOVATIONS Referral transport (17) Immunisation and IYCF (27) IEC/ BCC (18)

ARSH (5) Health insurance (8) Contracting out management of health facilities (14) Social franchising (4) Inceentivising human resources to improve access,

performance and range of services (8) Mobile Health clinics (11) Community involvement (28) Programme Monitoring and Management Information

Systems (13) Incentives to improve mobility, availability and

attendance of staff (22)27

Paradigm shift envisaged under RCH II is well underway

RCH II DESIGN PROGRESSFocusing on results Emphasis on outcomes since all states/UTs set targets for

IMR, MMR and TFR as well as underlying indicators; and spell out strategies and activities for meeting targets.

Flexible financing System of allocating “flexi funds” to states, preparation and appraisal of PIPs established.

Encouraging innovative approaches to improve RCH outcomes

Over 200 innovations identified across 25 states.3154 private facilities (equivalent to 12% of total PHCs and CHCs) have been accredited to provide ANC and delivery services.

Decentralisation and bottom up planning

DHAPs increased from 284 in 2006-07 to 488 in 2007-08.States have increasingly veered towards community ownership, engaging community and PRIs in monitoring of health programs and management of health facilities.

Pro poor focus Equity is a central theme in a large number of innovations.

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THANK YOU